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Case History - Feeding
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Patient Information
Patient Name
First
Last
Today's Date
MM slash DD slash YYYY
Person filling out questionnaire
First
Last
Relationship to patient
Your email address
Birth History
At how many weeks was your child born?
What was your child’s birth weight?
How many days were you and your child in the hospital?
Please describe your child’s conception
(natural, IVF, etc.)
Please describe your child’s delivery
(natural, caesarian, etc.)
Did your child have any feeding issues in the hospital?
Yes
No
If yes, please describe:
Did your child have any breathing issues in the hospital?
Yes
No
If yes, please describe:
Developmental History
At what age did your child:
Smile
Colors
Hold head up
Count
Roll over
Alphabet
Reach for an object
Demonstrate handedness
Transfer an object
Bladder Trained (days)
Crawled
Eat with utensils
Stood alone
First words
Walked
Ran
1-step derivatives
2-word phrases
Feeding History
Describe in your own words what problem your child is having with feeding:
Was your child breast-fed?
Yes
No
If yes, please describe:
Was your child bottle-fed?
Yes
No
If yes, please describe:
Please describe your child’s initial skill on the breast and/or bottle?
During feedings, did your child have any issues with arching?
Yes
No
If yes, please describe:
During feedings, did your child have any issues with crying?
Yes
No
If yes, please describe:
During feedings, did your child have any issues with sitting-up?
Yes
No
If yes, please describe:
During feedings, did your child have any issues with gagging?
Yes
No
If yes, please describe:
Is your child receiving services?
Yes
No
If yes, please describe:
During feedings, did your child have any issues with coughing?
Yes
No
If yes, please describe:
Is your child still breast and/or bottle-fed?
Yes
No
If no, please describe the weaning process and why the child was weaned:
Does your child use a cup?
Yes
No
If yes, what kind?
What age did your child begin baby cereal?
Yes
No
Please describe if there were any difficulties during this transition.
What age did your child begin baby food?
Yes
No
Please describe if there were any difficulties during this transition.
What age did your child begin finger foods?
Yes
No
Please describe if there were any difficulties during this transition.
What age did your child begin table foods?
Yes
No
Please describe if there were any difficulties during this transition.
List the foods that your child currently will eat and drink:
Put a star next to their favorites.
List the foods that your child refuses to eat and drink.
When provided with a food your child dislikes, how does your child respond?
List all the foods your child is allergic to:
Is your child on a special diet?
Yes
No
If yes, what type and when was it initiated?
Who typically feeds your child?
Who typically eats with your child?
What type of chair is used?
Are there any activities going on during meals?
How long do meals last typically?
Does your child use utensils or any type of special cups/bowls, etc.
Yes
No
If yes, please describe:
List foods your child used to eat, but not anymore?
What times does your child typically eat and what?
Include breakfast, lunch, dinner, and snacks if applicable.
Eating Times
Bottle, Breast, Liquids
Solids
How do you know if your child is hungry or full?
Has your child lost or gained any weight in the last 6 months?
Yes
No
If yes, how much:
Would you describe your child’s weight as:
Ideal
Underweight
Overweight
Does your child have/had dental problems?
Yes
No
If yes, please describe:
Does your child have/had frequent constipation problems?
Yes
No
If yes, please describe:
Does your child have/had frequent diarrhea problems?
Yes
No
If yes, please describe:
Does your child have/had vomiting problems?
Yes
No
If yes, please describe:
Does your child have/had choking problems?
Yes
No
If yes, please describe:
Does your child have/had gagging problems?
Yes
No
If yes, please describe:
Does your child have/had coughing problems?
Yes
No
If yes, please describe:
Does your child take a vitamin supplement?
Yes
No
If yes, which one:
Describe how you and your child feel after a feeding:
You:
Your child:
What other evaluations/specialties have you seen regarding your child’s feeding difficulties and what were the results?
Who was the specialist seen?
What treatments have been tried for this problem and what were the results?
What school is your child attending?
With what frequency does your child attend school?
Is your school assisting in any way with your child’s difficulties?
How can we be most helpful to you and your child?
Sensory History
For each question, place a check yes or no in the column that best describes your child. Compare with other children you know of the same age.
Tactile Sensation
Does your child seem sensitive to certain fabrics and avoid wearing clothes made of them?
Yes
No
Have trouble changing to new types of clothing when seasons change?
Yes
No
(i.e. from long pants to shorts)
Avoid going barefoot?
Yes
No
(i.e. in sand or grass)
Become irritated by tags on clothing?
Yes
No
Seem to crave being held or cuddled?
Yes
No
Express discomfort when touched by other people, even as in a friendly hug or pat?
Yes
No
Tend to bump or push others?
Yes
No
Seem overly sensitive to pain?
Yes
No
(i.e. especially bothered by small cuts)
Seem less sensitive to pain than others?
Yes
No
(i.e. to falls and bruises)
Mouth objects or clothing often?
Yes
No
Have difficulty judging how much strength to use?
Yes
No
(i.e. When petting animals may use too much force)
Gustatory Sensation
Act as though all food tastes the same?
Yes
No
Explore by tasting?
Yes
No
Dislike goods of certain texture?
Yes
No
Chew or lick non-food items?
Yes
No
Olfactory Sensation
Discriminate odors?
Yes
No
React defensively to smell?
Yes
No
Is bothered by smells that most other people don’t notice?
Yes
No
Visual Sensation
Become easily distracted by visual stimulation?
Yes
No
Express discomfort at bright lights?
Yes
No
Avoid or have difficulty with eye contact?
Yes
No
Have a hard time picking out a single object from many?
Yes
No
(i.e. finding a specific toy in the toy box)
Have difficulty with a camera flash, seems irritated by it?
Yes
No
Feeding
Need assistance to feed him/herself?
Yes
No
Tend to eat in a sloppy manner?
Yes
No
Frequently spill liquids?
Yes
No
Have trouble chewing?
Yes
No
Have trouble swallowing?
Yes
No
Have difficulty eating foods with lumps?
Yes
No
Stuff or put too much food in his/her mouth?
Yes
No
Explore objects by smelling them?
Yes
No
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